Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:

Effective Date: 09/18/1995

Title: Sterilization

Revision Date: 01/01/2018

Document: BI065:00

CPT Code(s): 55250, 58600-58615, 58670-58671, 58700

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Elective Sterilization is a covered service. Any hospital confinement solely for sterilization requires pre-authorization; outpatient procedures do not. BI059 Reversal of Sterilization procedure is not covered.

Medical Statement

1) Elective Sterilization is a covered service. Any hospital confinement solely for sterilization requires pre-authorization; outpatient procedures do not.

2) BI059 Reversal of Sterilization procedure is not covered.

3) For coverage considerations regarding the Essure Device, see BI372.

Codes Used In This BI:

55250	Removal of sperm duct(s)
58600	Division of fallopian tube
58605	Division of fallopian tube
58611	Ligate oviduct(s) add-on
58615	Occlude fallopian tube(s)
58670	Laparoscopy tubal cautery
58671	Laparoscopy tubal block
58700	Removal of fallopian tube

Limits

QualChoice reviews and authorizes services and substances. Billing and procedure codes change from time to time and QualChoice medical policies may not always reference the current published codes. This does not change the intent or effect of the policy language, nor does it affect the necessity for appropriate process. The codes are included in Medical Policies as a convenience to the readers of the policy.

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.